When we first met Lucy, she was a four-month-old, exuberant husky mix puppy. She came to our hospital in August of 1999 for her initial physical examination and puppy immunizations. Lucy was very healthy. Little did we know that less than six weeks later she would return to Berkshire Veterinary Hospital with a rare life-threatening disease.
On September 24th Lucy's owners knew something was wrong. Over the previous twenty-four hours Lucy had been having difficulty breathing, was constantly drooling, and was becoming very tense when her owners picked up. She had been completely normal the day before, as were their other two dogs.
When Dr. Makuc examined Lucy he found many abnormalities. Lucy could barely walk and when she did, her gait was short and stilted. Her ears were unusually erect, and her pupils were very small. Her mouth was clamped tight, and could barely be opened for examination. As her exam progressed it was clear that all her muscles were very tense. Her temperature was normal and her heart rate was just slightly elevated. There were no signs of trauma on her body. At this point, there were many diseases to consider that might cause her symptoms. At the top of that list were diseases that were known to abruptly attack the nervous system. Poisonings, toxin producing infections, meningitis, or primary neurologic disease were all considered.
Further questioning of her owners by Dr. Makuc determined that it was unlikely she would have ingested a toxin or poison. It was also unlikely she had been traumatized. However, all three of the dogs were reported to have found a bat out in the yard one to two weeks prior to this presentation. And, while the other two dogs were vaccinated for rabies, Lucy had yet to receive this vaccine. She had been too young on her initial visit. The owners were unable to recall any incidents or previous similar behavior.
With this information in hand it was likely Lucy's problem was neurologic in origin, probably some type of toxin, including tetanus which is very rare in dogs, or a bacterial or viral infection, possibly even rabies.
Because rabies can cause a very wide range of neurologic symptoms, and because it is transmissible to people, it is important to consider it when any patient presents with neurologic disease. Precautions are taken to prevent exposure to body fluids, especially saliva.
Lab tests were drawn, an intravenous catheter was placed, and Lucy was hospitalized in intensive care. She was started on fluid support, a broad-spectrum antibiotic, and continuous monitoring. Safeguards were taken to protect the staff and other patients against the possibility of rabies.
As Dr. Makuc and the other BVH veterinarians considered Lucy's symptoms, her history, and her age the decision was made to treat her for Tetanus. Tetanus is a very rare and often fatal disease in the dog. Success often depends on early treatment, and vigorous supportive care.
A toxin produced by the bacterium Clostridium tetani causes tetanus. Treatment not only involves appropriate antibiotics to kill the bacterial organism; it also involves the use of an antitoxin to prevent further neurologic damage from the toxin already produced by the bacterium. Dr. Makuc was pleased to learn that BVH had a supply of tetanus antitoxin on hand. A muscle relaxant and sedative was also administered in an attempt to relieve the persistent muscle contraction caused by the potential neurotoxins.
Over the next 24 hours Lucy's condition deteriorated. In spite of treatment she was unable to relax her muscles. She could not stand, eat, or even move her head. She exhibited opisthotonos, defined as muscle rigidity, especially of the back and limb muscles. And then she began to have seizures. Her owners were given a very guarded prognosis. Lucy's chances for survival were decreasing as her symptoms progressed. The clinical symptoms of tetanus patients would generally follow the same course as Lucy's and if treatment is unsuccessful, seizures are likely to be followed by respiratory arrest and death. If Lucy became unable to breathe she would have to be maintained on a respirator. After lengthy consultation with Dr. Makuc, Lucy's owners agreed to continue treatment. Fortunately, the progression of her symptoms stopped with the seizures. The seizures were controlled with intravenous anticonvulsant medication.
Lucy's condition seemed to stabilize by her third day in intensive care. There were no seizures and her muscles were a little less rigid. She could not lift her head but if you talked to her, and watched closely you could see slight movement in her tail. Lucy was offered a nutritional gruel and if fed carefully by hand, she was able to swallow small amounts of food. Tetanus recovery is often a very gradual process and recovery may take a month or more. Dr. Makuc knew that Lucy would need more vigorous nutritional support. Hand feeding and oral tube feeding were possible but if Lucy had difficulty with these procedures, there was always the risk of aspiration pneumonia. The decision was made to briefly anesthetized her and insert a feeding tube through her skin, directly into her esophagus. This would allow the support staff to administer greater amounts of food without the risk of aspiration pneumonia. Even if she could not swallow, the food would be delivered directly to her stomach. Lucy's nutritional requirements would be met.
Lucy's treatment plan was in place. She was on continuous intravenous support, nutritional support through her esophagostomy tube, anticonvulsants, muscle relaxants, and antibiotics. All of these elements were critical components of her treatment but twenty-four nursing care would be essential for her recovery. Lung damage will quickly occur in any recumbent patient that cannot move.
The lower lung becomes compressed and congested. Lucy could not move and she needed to be turned from side to side every few hours around the clock. Her IV line and her esophagostomy tube needed to be constantly monitored. Her bedding had to be changed regularly, and she had to be kept as clean as possible to prevent secondary infection. Excessive stimulation had to be minimized to help prevent the over-reaction to sight and sound that would result in violent episodes of muscle contraction. Nursing care often makes the difference whether or not a patient with tetanus survives and the doctors and technicians at BVH made certain that Lucy had all the nursing care and TLC that she needed. It was often difficult to see Lucy in this state. Imagine having all of your muscles in a constant state of contraction for days. It goes without saying that the entire staff and Lucy's owners were praying that she would make it and that all of our efforts and the discomfort she had endured would be worthwhile.
It was on the fifth day of hospitalization that Lucy really "turned the corner". She was actually wagging her tail when we talked to her. It was the only part of her that moved, but move it she did. Without any question she was letting us know that she was glad to be alive.
It was really incredible to watch her come back. It seemed that almost hourly you could see improvement. First she was able to lift her head a little and then a lot. By the sixth day she could stand; much like a sawhorse, but she could stand. By day seven she made slight attempts to move her front legs.
Throughout her hospitalization, Lucy's owners were constantly updated with progress reports. They visited often and were able to see that progress was being made. They were anxious to take part in her recovery and by day eight, Lucy was able to spend evenings and overnight at home. Her IV support was discontinued, and her owners were taught to feed her through her tube. Both of Lucy's owners worked during the day, so during those hours Lucy was readmitted to the hospital. By the end of the second week Lucy was beginning to show real signs of improvement. She began to try to eat on her own. And finally, as incredible as it seemed, she was even making attempts to walk on her own. I have to say that those first steps were a very emotional moment for the staff and her owners. Lucy was getting stronger by the day and eventually her feeding tube was removed.
Happily one month after she was stricken with the disease Lucy was running around like a normal four month old puppy, playing with her other dog friends and bringing smiles to all the people who played a role in her recovery.
The disease tetanus is caused by the entry of the bacterium Clostridium tetani into a wound. Once in the body the bacteria multiplies and produces a potent neurotoxin. The toxin is attracted to nerve tissue where it works to cause constant stimulation and thus muscle activity. According to Craig Greene, D.V.M., M.S. in Infectious Diseases of the Dog and Cat, the horse is the most susceptible animal to contract tetanus, humans are three times less likely to contract it and the dog is six hundred times less likely to become infected. The cat is seven thousand, two hundred times less likely to get it. That is why horses and people need vaccines against tetanus while neither dogs nor cats are vaccinated. Diagnosis of the disease is not easy and is based primarily on history and clinical signs. Although a bacteria, it is very difficult to culture and there are no reliable test to confirm it.
Most people or animals that get tetanus do so by introduction of the organism through a bite or puncture wound of some nature. The organism is all over our environment, especially in the soil. Thus the concern whenever a person is bitten or steps on a rusty nail. In Lucy's case no wound was ever found; however it is possible to be exposed to the organism up to three weeks before the first signs of illness, plenty of time for a wound to heal. Lucy was also at the age where she was "teething" and some veterinarians have speculated that the organism might gain entry as new teeth are erupting. Regardless of the route of entry, once the bacteria starts to multiply and produce toxin, the end result is the same, an extremely serious, life-threatening disease.
Fortunately for Lucy she survived. Not only was she a strong patient but her owners were equally strong and, in spite of a quarded prognosis, made the choice to give her the chance. She beat the odds. She was truly a unique case and will be forever remembered by the staff at Berkshire Veterinary Hospital.